Nasal surgery for the treatment of nasal obstruction, cosmetic deformity, trauma, or neoplasm is one of the most common surgeries performed among otolaryngologists, facial plastic surgeons, and general plastic surgeons and provides improved patient quality of life and productivity. Present solutions for understanding and learning how to perform key surgical procedures is difficult to teach due to the complex nasal anatomy and limited visualization of the anatomical structures during surgery. Furthermore, the nose is a very prominent structure on the face and any imperfectly performed procedures are quite visible, limiting the willingness of teachers to allow their trainees to perform key procedures, significantly limiting successful surgical training.
Septoplasty or submucous resection of the deviated septum has been the mainstay of surgical correction for nasal obstruction. It was found to be the third most commonly performed surgical procedure within otolaryngology, third only to myringotomy and tonsillectomy. See Manoukian P D, Wyatt J R, Leopold D A, Bass E B. Recent trends in utilization of procedures in otolaryngology-head and neck surgery. Laryngoscope (1997)107(4):472-477. This procedure is often performed through the nostril (transfixion or hemitransfixion incision) or through an open rhinoplasty approach. Both of these approaches limit the visibility of the working field only to the primary surgeon, making training and surgical instruction difficult. Failure to maintain the integrity of the mucosa on both sides of the septum can lead to a chronic nasal septal perforation which has significant impacts on patient quality of life. See Bohlin L, Dahlqvist A. Nasal airway resistance and complications following functional septoplasty: a ten-year follow-up study, Rhinology (1994) 32(4):195-197. Turbinoplasty is another commonly performed procedure aimed at improving nasal airflow in which limited visualization of the structure can limit surgical teaching and trainee understanding.
Increasingly, nasal valve dysfunction (NVD) is being recognized as an underdiagnosed, distinct, and surgically treatable cause of nasal obstruction. When present, and when septoplasty alone is performed, it has been found to be a cause of persistent nasal obstruction and need for revision surgery. See Becker S S, Dobratz E J, Stowell N, Barker D, Park S S. Revision septoplasty: review of sources of persistent nasal obstruction, Am J Rhinol. (2008) 22(4):440-444. The external nasal valve, formed by the caudal septum, medial crura of the lower lateral cartilages, alar rim, and nasal sill, and the internal nasal valve, formed by the upper lateral cartilages, dorsal septum, and head of the inferior turbinate, are cross-sectional areas of the nasal cavity with the greatest overall resistance to airflow and thus dominant determinants of nasal patency. Dysfunction can occur either due to narrowing of these areas or as a result of lateral nasal wall collapse in the setting of a weak lateral wall owing to the Bernoulli effect as air accelerates through these segments.
Nasal reconstruction with procedures such as placement of spreader grafts, lateral crural strut crafts, alar batten grafts, and alar rim grafts, among others, are the most commonly performed procedures to correct NVD and have been found to be effective at relieving nasal obstruction. Given the growing evidence supporting the importance of recognizing and treating NVD for symptomatic relief of nasal obstruction, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published a Clinical Consensus Statement (CCS) in 2010 to enhance awareness. The CCS defined NVD as a distinct and primary cause of nasal obstruction that can be successfully treated with surgical intervention. See Rhee J S, Weaver E M, Park S S, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise, Otolaryngol Head Neck Surg. (2010) 143(1):48-59. Unfortunately, techniques to treat NVD are quite complex and many surgeons do not feel comfortable with this procedure, leading it to be frequently overlooked, leading to a high failure and revision rate.
Nasal osteotomies are another common procedure performed during rhinoplasty, both for functional and cosmetic indications. Performance of nasal osteotomies are difficult to teach as they are performed blindly and by tactile feedback alone. A recent study found that most facial plastic surgeons do not allow trainees to perform this critical step in rhinoplasty. See Chen J X, Kozin E D, Dedmon M M, Lee L N. Teaching and practice patterns of lateral osteotomies for rhinoplasty, Am J Otolaryngol. (2017) 38(4):498-500. Further, teaching sessions using cadaveric specimens were found to increase trainee understanding and confidence with the procedure. See Chen J X, Kozin E D, Shaye D A, Hadlock T, Lindsay R, Lee L N. Educational Cadaveric Module for Teaching Percutaneous and Intranasal Osteotomies in Rhinoplasty, Otolaryngol Head Neck Surg. (2017)156(6):1088-1090. Unfortunately, cadaveric specimens are expensive and difficult to obtain.
Surgical simulation would allow for improved teaching, practice, and understanding of these procedures. Surgical simulation has gained increasing popularity in the United States medical curriculum and has been found to lead to improved surgical performance, medical knowledge, procedural comfort, and skill retention. The Association of Medical Education in Europe (AMEE), a worldwide organization for medical education, reported that simulation-based healthcare education can be used to help novice trainees become proficient in specific tasks and that simulation-based healthcare education with deliberate practice leads to improved and lasting results compared with traditional clinical education. See Motola I, Devine L A, Chung H S, Sullivan J E, Issenberg S B. Simulation in healthcare education: a best evidence practical guide, AMEE Guide No. 82. Med Teach. (2013) 35(10):e1511-1530.
Finally, patient understanding of nasal anatomy and the structures that are targeted in these surgeries is quite limited. An anatomically accurate model that can explain the procedures they are undergoing can help improve patient understanding, communication, and expectations.